HOSPITAL STUDY TO UNDERSTAND QUALITY OF CARE AND RSBY IMPLEMENTATION EXPERIENCE: IMPLICATIONS FOR PM-JAY

BACKGROUND

z India is committed to the goal of achieving Universal Health Coverage (UHC) India recently announced an ambitious health insurance scheme (ICMR, PHFI and IHME, 2017)

z The new health insurance, PM-JAY builds upon its predecessor insurance scheme RSBY (RSBY, 2008-2018) (Government of India, n.d)

z IGSSP provided technical support to NHA for conducting evaluation of RSBY, which will serve as a baseline for PMJAY

z This poster describes the supply side experience and quality of care as well as its significance for PMJAY

STUDY AREA

DESIGN AND METHODS z Cross sectional research design

zMix method approach (both quantitative and qualitative techniques)

zMulti-stage & purposive sampling

z Qualitative and quantitative interviews are conducted with Hospital Administrator, Director, General Physician (treating RSBY Patients), Financial Administrator as well as exit interviews with patients

RESULTSEmpanelment of Hospitals

CONCLUSIONS AND RECOMMENDATIONSImplementation

FOR MORE INFORMATION Dr. Sharmishtha Basu Sharmishtha.basu@giz.de

Dr. Nishant Jain and Dr. Sharmistha Basu 1 GIZ, New Delhi

BiharPatna, MuzaffarpurNo health insurance scheme operational

GujaratAhmedabad, Surat

ChhatisgarhRaigarh, Bilaspur

z Public facilities at CHC level and above, providing secondary and tertiary care services, get empaneled as per Government mandate

z Empanelment of hospitals under schemes is time taking process (Gujarat - 2 to 6 months; Chhattisgarh - 3 weeks to 8 months)

z All hospitals fulfilled the mandatory criteria for manpower, infrastructure, and had defined processes for storing medical records

z In Gujarat, most hospitals (esp. private) empaneled under MA Yojana were NABH accredited

z Motivation for hospital empanelment includes social responsibility, service outreach, and profit making

Information management

z Public hospitals – patient and hospital related data is stored in hard & soft copy formats

z Private hospitals – Majority use HIMS to store patient and hospital related data

z Same beneficiary flow is observed across all hospitals

z Hospitals have a helpdesk and designated medical officer and staff to facilitate the care

z RSBY-empaneled hospitals face a delay in pre-authorization, approval and claims settlement

z In Chhattisgarh, irrational claims rejection was a barrier to provide care leading to referrals to other facilities by hospitals

Beneficiary and Claims Management (Standard Process)

Eligibility verification & registration

Pre-authorization & blocking of package

HospitalizationCashless medical/surgical treatment

Discharge and follow-up

Reasons cited by hospitals for non-empanelment (perceptions)

z Low package rates

z Delayed payments

z Irrational rejection of claims

Onlinesubmission of

application form

Physicalverication by

TPA/ISA

Report submitted to SEC

Hospitalempaneled under

the scheme

Quality of Care

z Accreditation:

z The insurance schemes do not comprehensively define the process for measuring quality of care, hospitals pursue it voluntarily

z In Gujarat, majority empaneled private hospitals are NABH accredited compared to very few in Chhattisgarh

z Clinical Protocols:

z NABH accredited and private corporate hospitals have well-defined STPs/ SOPs and are being followed as well

z Training & Capacity Building:

z In Gujarat, private hospitals have a training schedule and provide trainings

z No differentiation in quality of care between scheme and non-scheme patients

z Patient Satisfaction

z Hospitals have grievance redressal mechanism and suggestion and compliant boxes, and emergency grievances are resolved at earliest

z Hospitals collect patient feedback at the time of discharge and evaluate in regular meetings and take necessary actions

Financial management

z Public Hospitals

− Claim amount is settled through RKS bank account − Utilization of claim’s revenue has a complex & time-taking

process and the hospital has a limited autonomy in utilizing these funds

− In Chhattisgarh, hospitals couldn’t improve infrastructure and recruit manpower to manage the increased patient load

z Private Hospitals

− Hospitals were able to improve physical infrastructure, recruit manpower and add additional services

− In Gujarat, because of MA Yojana, the hospitals were able to upgrade to high-end technology devices over a period of time

− Low package rates, delayed payments and irrational claim rejections were the key reasons cited for irregularities in cashflow

− Hospitals reported concerns over providing quality care citing low package rates

Non-empaneled hospitals, N=20Empaneled hospitals, N=20

Private Private

Guj

arat G

ujar

at

Chh

atti

sgar

h

Chh

atti

sgar

h

Private

PrivatePublic

Public

3 4

2 2

2

1 1 1

2 2

2

3 6

6

3

High ■ 0.8 – 1.0 Medium ■ 0.6 – 0.7 Low ■ < 0.6

Rationalization of package rates

Reduction in time for empanelment

Improved coordination with TPA/IC for speedy document processing and reducing irrational claim rejections

Public hospitals should have more flexibility on using scheme funds to upgrade infrastructure and manpower

Structured financial management with standard process to ensure efficiency

Focused IEB/BCC activities to improve awareness and patient experience

Quality of care

Implementation and enforcement of Standard Treatment Protocols/standard treatment guidelines

Promotion of NABH accreditation of hospitals and mandating accreditation (entry level) for empanelment

Incentive based quality accreditation can be promoted

Capacity building, training for hygiene practices, and standard bio-medical waste (BMW) process through scheme administration

REFERENCES:

1. Indian Council of Medical Research, Public Health Foundation of India, and Institute for Health Metrics and Evaluation. India: Health of the Nation’s States — The India State-Level Disease Burden Initiative. 2017 New Delhi, India: ICMR, PHFI, and IHME.

2. Government of India.n.d.National Health Authority, Pradhan Mantri-Jan Arogya Yojna (PM-JAY); https://www.pmjay.gov.in/

A total of 9 indicators were considered and a weighted score is assigned to each indicator to calculate additive index

50 20

hospitals in 6 districts of 3 states (i.e. 2 districts in each state*)

hospitals from each State (10 Emp and 10 Non-emp), except in Bihar (10 non-empaneled)

Input based indicators Process based indicators

Avalability of services Infrastructure & equipment HR Sops and guidelines Quality grading Accessibility

Availability of functional OT

Availabili-ty of labor

room or ob-stetric ser-

vices

Availability of floor plan & sig-nages inside facility

Availability of doctors 24*7

Availability of clinical STP and

diagnostic protocols

Protocol for biomedical waste

segregation

Accreditation of hospital

Motorable road for patient trans-

port

Ramp facility/lift for differently

abled